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18B â Background: 19Relevant medical history, medications, allergies, and shift events â only as mentioned in the transcript. 20 21A â Assessment: 22Current observations and clinical concerns as stated. Do not add clinical interpretations not expressed by the nurse. 23 24R â Recommendation: 25Pending tasks, monitoring, and escalation criteria â only as discussed. Do not add standard steps not mentioned.`},{label:"Discharge Summary",category:"structured",description:"Admission details through discharge diagnosis and follow-up",prompt:`Create a discharge summary template with the following structure: 26 27Admission Details: 28Include admission date, admitting diagnosis, and reason for hospitalization â only as stated in the transcript. 29 30Hospital Course: 31Summarize key clinical events and procedures as described. Do not fill in gaps with assumed information. 32 33Discharge Diagnosis: 34Record only the diagnosis explicitly stated by the clinician at discharge. Do not suggest or infer a diagnosis if not mentioned. 35 36Discharge Medications: 37List only medications with dosage and frequency as discussed. Do not add medications not mentioned. 38 39Follow-Up Instructions: 40Include only the follow-up steps, restrictions, and return criteria explicitly stated.`},{label:"Patient Letter",category:"letter",description:"Plain-language visit summary addressed directly to the patient",prompt:"Create a letter addressed directly to the patient in plain, non-technical language. Summarise the visit based only on what was discussed in the transcript. Explain findings in simple terms, using only information the clinician shared. State the diagnosis or impression only if the clinician explicitly communicated one â do not infer or suggest a diagnosis not stated. Describe the treatment plan and medications exactly as discussed, without adding advice not given. Include follow-up instructions only as mentioned. Do not add general health recommendations or warnings not raised in the consultation. Close with a contact number if provided."},{label:"Pathology Report",category:"hospital",description:"Specimen, macroscopic & microscopic findings, and diagnosis",prompt:`Create a histopathology report template with the following structure: 41 42Specimen: 43Identify the specimen type, site, laterality, and collection method as stated. 44 45Clinical Information: 46Record only the clinical context and working diagnosis provided by the requesting clinician. 47 48Macroscopic Description: 49Describe only the macroscopic findings explicitly stated. Do not add standard descriptors not mentioned. 50 51Microscopic Description: 52Document only the histological findings explicitly described. Do not infer pathology from findings. 53 54Diagnosis: 55State only the pathological diagnosis explicitly reached by the pathologist. Do not suggest a diagnosis or grade not directly stated. 56 57Comment: 58Include only ancillary testing requests and correlations explicitly discussed.`},{label:"Referral Letter",category:"letter",description:"Formal clinician-to-clinician referral with history and clinical question",prompt:"Create a formal referral letter template addressed from one clinician to another. The letter should open with the date, the recipient's name and title, and the patient's full name, date of birth, and contact details as provided. The first paragraph should state the reason for referral and urgency exactly as expressed by the clinician. The second paragraph should summarize only the medical history, medications, allergies, and investigation results explicitly mentioned in the transcript. The third paragraph should describe the specific clinical question being asked, without adding assumptions. Do not suggest a diagnosis or clinical interpretation not stated by the referring clinician. Close with the clinician's sign-off details."},{label:"Community Physio (Outpatient)",category:"allied health",description:"Assessment, treatment, home exercise program & follow-up plan",prompt:`Create a community outpatient physiotherapy assessment and treatment note with the following structure: 59 60Referral & Presenting Complaint: 61Record the referral source and the patient's primary complaint in their own words as stated. Do not add clinical context not mentioned. 62 63Subjective History: 64Document onset, mechanism, aggravating and easing factors, pain scale rating, functional limitations, and relevant past medical or surgical history â only as described
64in the transcript. 65 66Objective Assessment: 67Record only the physical examination findings explicitly stated: posture, range of motion, strength testing, special tests, neurological screen, and gait analysis. Leave any component blank if not assessed or mentioned. 68 69Impairment Summary: 70State only the clinical impairments identified and documented by the physiotherapist. Do not infer or add impairments not directly discussed. 71 72Goals: 73List only the short- and long-term functional goals collaboratively set and explicitly stated during the session. 74 75Treatment Provided: 76Document only the interventions delivered in this session as described â manual therapy, exercise, education, modalities, or other. Do not add standard techniques not mentioned. 77 78Home Exercise Program: 79List only the exercises prescribed, with sets, reps, and frequency as stated. If no HEP was given, leave blank. 80 81Plan & Follow-Up: 82Record the agreed review frequency, referral, or discharge plan as discussed. Do not add recommendations not raised.`},{label:"Registrar Assessment Note",category:"medical officer",description:"Presenting problem, history, exam, clinical reasoning & management plan",prompt:`Create a registrar-level clinical assessment note with the following structure: 83 84Presenting Problem: 85Document the acute or subacute clinical problem as stated. 86 87History: 88Record the detailed history of presenting illness, relevant past history, medications, allergies, and social context â only as explicitly discussed in the transcript. 89 90Examination: 91Document systematic examination findings only as described. Do not add findings not mentioned. 92 93Investigations: 94Summarise results reviewed or ordered â only as discussed during the consultation. 95 96Clinical Reasoning: 97Record the differential diagnosis and the reasoning explicitly expressed by the registrar. Do not add diagnoses or reasoning not directly stated. 98 99Impression: 100State the working diagnosis as documented. 101 102Plan: 103Document the management plan, including investigations, treatments, referrals, and senior discussion â only as stated. 104 105Consultant Review: 106Record any consultant input or advice given â only if explicitly mentioned.`},{label:"Nurse Practitioner / CNC Assessment",category:"nursing",description:"Referral reason, clinical assessment, management & follow-up",prompt:`Create a Nurse Practitioner or Clinical Nurse Consultant assessment note with the following structure: 107 108Referral / Reason for Review: 109State the reason for NP or CNC involvement and the referral source â as documented. 110 111Presenting Concern: 112Document the patient's presenting concern in their own words as stated. 113 114Health History: 115Record relevant medical history, surgical history, medications, allergies, and social determinants of health â only as explicitly mentioned. 116 117Clinical Assessment: 118Document focused physical assessment findings and any diagnostic tests ordered or reviewed â only as stated. Do not add findings not described. 119 120Diagnosis / Clinical Impression: 121Record only the diagnosis or clinical impression explicitly documented by the NP or CNC. Do not infer diagnoses not stated. 122 123Management: 124Document prescribing decisions, referrals, patient education, and follow-up planning â only as discussed. 125 126Patient Education Provided: 127Record the specific education or self-management information given â only if mentioned. 128 129Follow-Up: 130State the review plan and escalation pathway as documented.`},{label:"Registered Midwife â Antenatal Visit",category:"midwifery",description:"Gestation, clinical assessment, fetal wellbeing & antenatal plan",prompt:`Create a registered midwife antenatal visit note with the following structure: 131 132Gestation & Visit Type: 133Record gestation in weeks and days, and the type of visit (routine, urgent, or specialist-referred) as stated. 134 135Presenting Concerns: 136Document the woman's concerns and reported symptoms â in her own words â only as stated. 137 138Obstetric History: 139Record gravida, para, and relevant obstetric history â only as explicitly mentioned. 140 141Relevant Medical & Medication History: 142List co-morbidities, current medications, and allergies as stated. 143 144Clinical Assessment: 145Document vital signs, fundal height, fetal presentation, fetal heart rate, urinalysis, and any other assessments â only as explicitly described. Leave any component blank if not performed or mentioned. 146 147Screening & Investigations: 148Record any bloods, ultrasound, or screening results discussed â only as stated. 149 150Fetal Wellbeing: 151Document fetal movement reporting and any formal wellbeing assessment only if discussed. 152 153Clinical Impression: 154State only the clinical findings or concerns documented by the midwife. Do not add interpretations not stated. 155 156Plan & Referrals: 157Record the agreed antenatal plan, any specialist referrals, and next appointment â only as discu
157ssed. 158 159Education & Support Provided: 160Document only the information and support offered during this visit as mentioned.`},{label:"Occupational Therapist Assessment",category:"allied health",description:"Occupational profile, functional assessment, goals & equipment",prompt:`Create an occupational therapy assessment and intervention note with the following structure: 161 162Referral & Reason: 163State the referring source and the OT referral reason as documented. 164 165Occupational Profile: 166Record the patient's roles, routines, occupational priorities, and home environment â only as described in the transcript. 167 168Presenting Concerns: 169Document the patient's and carer's stated concerns regarding occupational performance. 170 171Functional Assessment: 172Record findings from formal or observational assessments of ADL, IADL, cognition, upper limb function, or work capacity â only as explicitly performed and described. State assessment tool names and scores if mentioned. 173 174Occupational Performance Issues: 175List only the occupational performance issues identified and prioritised during the assessment. 176 177Goals: 178Document only the short- and long-term occupational goals collaboratively set and explicitly stated. 179 180Intervention Provided: 181Record only the OT interventions delivered this session â equipment prescription, task modification, cognitive strategy training, splinting, or other â as described. 182 183Equipment & Home Modifications: 184List only the equipment recommended or trialled and modifications discussed â with rationale if stated. 185 186Plan & Follow-Up: 187Record the agreed review frequency, discharge criteria, or onward referral â only as discussed.`},{label:"Speech Pathologist Assessment",category:"allied health",description:"Communication & swallowing assessment, IDDSI recommendations & plan",prompt:`Create a speech pathology assessment and management note with the following structure: 188 189Referral & Reason: 190Document the referral source and the reason for speech pathology involvement as stated. 191 192Presenting Concerns: 193Record the patient's or carer's concerns regarding communication, swallowing, or voice â as stated. 194 195Relevant History: 196Include medical history, surgical history, and any prior speech pathology input â only as explicitly mentioned. 197 198Communication Assessment: 199Document findings from formal or informal assessment of speech, language, voice, or fluency â only as performed and described. Include assessment tool names and scores if stated. 200 201Swallowing Assessment: 202Record clinical swallowing examination findings, including oromotor assessment, trial textures and liquid consistencies, and any instrumental assessment results â only as explicitly described. Do not add standard findings not mentioned. 203 204Diagnosis / Clinical Impression: 205State only the communication or swallowing diagnosis explicitly documented by the speech pathologist. Do not infer diagnoses not stated. 206 207Dietary / Fluid Recommendations: 208Record IDDSI texture and fluid level recommendations only if explicitly stated. Do not suggest levels not discussed. 209 210Intervention & Education: 211Document only the therapy provided and education given this session as described. 212 213Plan & Follow-Up: 214State the frequency of review, goals, and any onward referral â only as discussed.`},{label:"Dietitian Nutrition Assessment",category:"allied health",description:"Dietary history, nutrition diagnosis, requirements & care plan",prompt:`Create a dietitian nutrition assessment and care plan note with the following structure: 215 216Referral & Reason: 217State the referral source and the nutrition-related reason for review as documented. 218 219Nutrition-Focused History: 220Record dietary intake, appetite, weight history, relevant gastrointestinal symptoms, and feeding route â only as explicitly stated. 221 222Anthropometric Data: 223Document weight, height, BMI, and recent weight change â only as recorded. Note measurement method if stated. 224 225Nutrition Screening / Assessment Tool: 226Record the screening or assessment tool used and the result â only if explicitly performed. 227 228Clinical Context: 229Summarise the relevant medical diagnosis and comorbidities only as they relate to nutrition and as stated. 230 231Nutrition Diagnosis: 232State only the nutrition diagnosis explicitly documented by the dietitian. Do not suggest a nutrition problem not directly expressed. 233 234Nutrition Requirements: 235Record estimated energy, protein, and fluid requirements only if calculated and stated by the dietitian. 236 237Nutrition Intervention: 238Document the dietary prescription, oral nutrition supplement, enteral or parenteral nutrition plan, or behaviour change strategies â only as discu
238ssed. 239 240Monitoring & Evaluation: 241Record the parameters to be monitored and the review frequency â only as stated. 242 243Goals & Education: 244List the nutrition goals and education provided â only as documented.`},{label:"Social Worker Psychosocial Assessment",category:"allied health",description:"Social history, risk assessment, interventions & support plan",prompt:`Create a social work psychosocial assessment note with the following structure: 245 246Referral & Reason: 247State the referral source and the reason for social work involvement as documented. 248 249Presenting Concern: 250Record the patient's and carer's presenting concerns in their own words â only as stated. 251 252Social & Family History: 253Document living situation, household composition, social support networks, and relevant family history â only as explicitly described. 254 255Functional & Carer Capacity: 256Record the patient's current functional status and the carer's capacity and needs â only as stated. 257 258Financial & Legal: 259Include housing security, income, insurance, and any guardianship or legal matters â only if mentioned. 260 261Risk Assessment: 262Document any risks to the patient or others â including safeguarding concerns, domestic violence, or self-harm â only as explicitly raised and documented. Do not infer risk. 263 264Cultural & Spiritual Considerations: 265Record cultural background, language needs, and spiritual considerations only if mentioned. 266 267Psychosocial Formulation: 268State only the psychosocial summary explicitly documented by the social worker. Do not add interpretations not stated. 269 270Intervention & Referrals: 271Document actions taken â community linkages, referrals, advocacy, or crisis intervention â only as described. 272 273Plan & Follow-Up: 274Record the agreed support plan and review interval â only as discussed.`},{label:"Pharmacist Medication Review",category:"allied health",description:"Medication list, drug-related problems & prescriber recommendations",prompt:`Create a clinical pharmacist medication review note with the following structure: 275 276Reason for Review: 277State the reason for the pharmacist review â polypharmacy, medication safety, discharge reconciliation, or other â as documented. 278 279Current Medications: 280List all medications with dose, frequency, and route â only as stated or reconciled during the review. Note any discrepancies identified. 281 282Allergies & Adverse Drug Reactions: 283Record documented allergies and ADRs as stated. 284 285Medication-Related Problems Identified: 286List only the drug-related problems explicitly identified by the pharmacist â interactions, contraindications, inappropriate dose, adherence issues, or unnecessary medications. Do not add problems not discussed. 287 288Clinical Context: 289Summarise the relevant medical conditions and organ function parameters only as they relate to medication management and as stated. 290 291Recommendations: 292Document only the pharmacist's recommendations â dose adjustments, deprescribing, substitutions, monitoring, or counselling â as explicitly stated. Do not add standard recommendations not discussed. 293 294Prescriber Communication: 295Record any recommendations communicated to the prescribing clinician and their response â only if documented. 296 297Patient / Carer Counselling: 298State the medication education and counselling provided â only as described. 299 300Follow-Up: 301Record the monitoring plan and review interval as discussed.`},{label:"Exercise Physiologist Session Note",category:"allied health",description:"Capacity assessment, exercise prescription, session delivery & review",prompt:`Create an accredited exercise physiologist assessment and session note with the following structure: 302 303Referral & Reason: 304State the referral source and the clinical indication for exercise physiology as documented. 305 306Health & Exercise History: 307Record relevant medical history, current medications, prior exercise history, and physical activity levels â only as explicitly stated. 308 309Functional Capacity Assessment: 310Document findings from any functional or exercise capacity assessments performed â test names, results, and heart rate or symptom response â only as described. Do not add normative data not discussed. 311 312Exercise Barriers & Preferences: 313Record stated barriers to exercise and the patient's preferences and goals â only as expressed. 314 315Exercise Prescription: 316Document the exercise program prescribed â modality, frequency, intensity, duration, and progression â only as explicitly stated. Do not add standard prescription parameters not discussed. 317 318Session Delivery: 319Record the exercise activities performed in this session and any modifications made â only as described. 320 321Response to Exercise: 322Document the patient's physiological and symptomatic response during the session â only as observed and stated. 323 324Education Provided: 325Record the self-management and exercise education given â only as mentioned. 326 327Goals & Outcome Measures: 328List the agreed goals and any outcome measures used â only as documented. 329 330Plan & Review: 331State the frequency of ongoing sessions and review criteria â only as discu
331ssed.`},{label:"Psychologist Clinical Assessment",category:"mental health",description:"History, MSE, risk assessment, formulation & treatment plan",prompt:`Create a psychologist clinical assessment note with the following structure: 332 333Referral & Presenting Problem: 334State the referral source and the presenting psychological concern as documented. 335 336Relevant History: 337Record developmental, trauma, psychiatric, medical, medication, and psychosocial history â only as explicitly stated in the transcript. 338 339Mental Status Examination: 340Document only the MSE components explicitly described: appearance, behaviour, affect, mood, speech, thought process, thought content, perceptual disturbances, cognition, insight, and judgement. Leave unmentioned components blank. 341 342Psychological Assessment: 343Record findings from any formal psychological tests, questionnaires, or structured interviews â test names, scores, and interpretation â only as described. Do not add normative comparisons not stated. 344 345Risk Assessment: 346Document risk to self and others â including ideation, intent, plan, and protective factors â only as explicitly assessed and stated. Do not infer risk level. 347 348Formulation: 349Record only the psychological formulation explicitly stated by the psychologist â predisposing, precipitating, perpetuating, and protective factors â only if discussed in these terms. 350 351Diagnosis / Clinical Impression: 352State only the diagnosis or clinical impression explicitly documented by the psychologist. Do not suggest a diagnosis not directly expressed. 353 354Treatment Plan: 355Document the therapeutic modality, session frequency, and treatment goals â only as stated. 356 357Outcome Measures: 358Record any outcome tools administered and scores â only if mentioned.`},{label:"Mental Health Clinician â Triage & Crisis",category:"mental health",description:"Crisis presentation, risk formulation, safety plan & disposition",prompt:`Create a mental health clinician triage and crisis assessment note with the following structure: 359 360Referral Source & Triage Category: 361Record the referral pathway â PACER, Access Mental Health, ED, inpatient, or community â and the triage urgency as documented. 362 363Presenting Crisis or Concern: 364Document the acute mental health presentation in the patient's own words and as described by the clinician â only as stated. 365 366Current Mental State: 367Record the mental state findings as explicitly described: behaviour, affect, mood, suicidal or homicidal ideation, psychotic features, and cognitive state. Do not add components not assessed. 368 369Risk Assessment: 370Document static and dynamic risk factors, protective factors, and the clinician's stated risk formulation â only as explicitly assessed. Do not infer risk rating. 371 372Collateral Information: 373Record information from carers, family, or services â only if explicitly obtained and documented. 374 375Relevant Psychiatric & Medical History: 376List prior psychiatric diagnoses, hospitalisations, medications, and relevant medical history â only as stated. 377 378Current Supports & Services: 379Document existing community mental health, NDIS, or other supports â only as mentioned. 380 381Clinical Impression: 382State only the working clinical impression or diagnosis documented by the clinician. Do not suggest diagnoses not directly expressed. 383 384Crisis Plan & Immediate Management: 385Record the agreed crisis safety plan, immediate interventions, and any escalation decisions â only as documented. 386 387Disposition: 388State the outcome â voluntary or involuntary admission, community follow-up, ED referral, or discharge with safety plan â exactly as documented.`},{label:"Allied Health Assistant Session Note",category:"allied health",description:"Delegated program activities, patient response & progress toward goals",prompt:`Create an Allied Health Assistant (AHA) treatment session note with the following structure: 389 390Supervising Clinician & Delegated Program: 391Record the name and role of the supervising allied health professional and the delegated treatment program being implemented â as documented. 392 393Session Date & Duration: 394State the date and length of the session as recorded. 395 396Program Activities Delivered: 397Document only the exercises, tasks, or therapeutic activities completed during the session â as per the delegated program. Note any modifications made and the reason if stated. 398 399Patient Response & Participation: 400Record the patient's engagement, reported symptoms, and observable response during the session â only as observed and stated. Do not make clinical interpretations. 401 402Progress Towards Goals: 403Document measurable progress indicators â repetitions, distance, time, or functional milestones â only as recorded. 404 405Concerns or Incidents: 406Record any patient concerns, adverse responses, or incidents that occurred â only as observed and reported. 407 408Communication to Supervising Clinician: 409Document what was communicated to the supervising clinician and any instructions received â only if explicitly stated. 410 411Next Session Plan: 412Record the agreed plan for the next session as delegated by the supervising clinician.`},{label:"GP Consultation Note",category:"general practice",description:"Chief complaint, history, examination, impression & plan",prompt:`Create a GP consultation note with the following structure: 413 414Date & Clinician: 415Record the date and clinician's name and role. 416 417Presenting Complaint: 418Document the patient's primary reason for attendance in their own words â only as stated. 419 420History of Presenting Illness: 421Record onset, duration, character, severity, associated features, and context â only as explicitly stated. 422 423Past Medical & Surgical History: 424List only what was mentioned. 425 426Medications & Allergies: 427Document as stated. Note any changes discussed. 428 429Family & Social History: 430Include family history, smoking, alcohol, occupation, and living situation â only if mentioned. 431 432Examination: 433Document vital signs and physical examination findings â only as explicitly described. 434 435Investigations:
436List results reviewed or tests ordered â only as discussed. 437 438Assessment / Impression: 439Record only the diagnosis or impression explicitly stated by the GP. 440 441Plan: 442Document prescriptions, investigations, referrals, and follow-up â only as discussed. 443 444Patient Education & Safety Netting: 445Record information and return-to-care advice â only if mentioned.`},{label:"Specialist Outpatient Consultation",category:"general",description:"Referral reason, examination, clinical impression & management recommendations",prompt:`Create a specialist outpatient consultation letter with the following structure: 446 447Date, Clinician & Recipient: 448Record the date, specialist's name and specialty, and the referring clinician â as stated. 449 450Reason for Referral: 451State the clinical question or indication â as documented. 452 453History of Presenting Condition: 454Document symptom course, prior investigations, treatments tried, and current functional status â only as explicitly stated. 455 456Relevant Medical & Medication History: 457Include co-morbidities, medications, and allergies â only as mentioned. 458 459Examination: 460Record targeted examination findings â only as explicitly described. 461 462Investigations Reviewed: 463Summarise relevant results â only as stated. 464 465Clinical Impression: 466State only the diagnosis or differential explicitly documented. 467 468Management Plan & Recommendations: 469Document agreed management and recommendations â only as stated. 470 471Follow-Up:
472Record the review interval and next steps as discussed.`},{label:"Progress Note / Daily Ward Note",category:"clinical note",description:"Clinical update, exam findings, investigations & daily management plan",prompt:`Create a daily inpatient progress note with the following structure: 473 474Date, Time & Clinician: 475Record as stated. 476 477Clinical Update: 478Document reported symptoms, overnight events, and interval changes â only as stated. 479 480Examination: 481Record vital signs and focused findings â only as explicitly described. 482 483Investigations: 484Summarise results reviewed â only as discussed. 485 486Assessment: 487Record the clinical impression and progress â only as stated. 488 489Plan: 490Document management decisions, medication changes, and investigations ordered â only as stated. 491 492Escalation / Consultant Input: 493Record senior review and advice â only if mentioned.`},{label:"Procedure / Operation Note",category:"procedure",description:"Procedure details, findings, specimens, complications & post-op plan",prompt:`Create a procedure or operation note with the following structure: 494 495Procedure Details: 496Record the procedure name, date, performing clinician, and assistant â as stated. 497 498Indication: 499State the clinical indication â as documented. 500 501Consent: 502Record whether consent was obtained â only as explicitly stated. 503 504Anaesthesia: 505Document type and agent â only if mentioned. 506 507Procedure Description: 508Summarise the steps as described. Do not add standard steps not discussed. 509 510Findings: 511Document only findings explicitly stated. 512 513Specimens: 514List specimens sent â only if mentioned. 515 516Complications: 517Record only complications explicitly noted. 518 519Post-procedure Plan: 520Document instructions and monitoring â only as stated.`},{label:"Medical Certificate",category:"certificate",description:"Fitness or incapacity statement with clinical basis and restrictions",prompt:`Create a medical certificate with the following structure: 521 522Patient Details: 523Record name, date of birth, and occupation â only as provided. 524 525Clinician Details: 526Document certifying clinician's name, qualification, practice address, and date â as stated. 527 528Clinical Basis: 529State only the clinical reason â as documented. 530 531Certificate Statement: 532Record the specific statement â fitness for work, incapacity period, restrictions â only as explicitly stated. 533 534Period Covered: 535State the dates â only as documented. 536 537Restrictions or Modifications: 538List work modifications â only as stated. 539 540Clinician Signature & Registration: 541Include name, registration number, and date â as documented.`},{label:"Medication Review Note",category:"review",description:"Reconciliation, drug-related problems & agreed medication changes",prompt:`Create a medication review or medicines reconciliation note with the following structure: 542 543Reason for Review: 544State the indication â as documented. 545 546Current Medication List: 547Record all medications with dose, frequency, and route â as stated. Note discrepancies. 548 549Allergies & ADRs: 550Document as stated. 551 552Medication-Related Problems: 553List only issues explicitly identified â interactions, duplications, inappropriate doses, or adherence concerns. 554 555Recommendations: 556Document only agreed changes â as stated. 557 558Patient / Carer Counselling: 559Record education provided â only as mentioned. 560 561Communication to Prescriber: 562Note recommendations conveyed and response â only if documented. 563 564Follow-Up: 565Record monitoring plan and review interval as stated.`},{label:"Handover Note / ISBAR",category:"handover",description:"Identify, Situation, Backgroun
565d, Assessment & Recommendation",prompt:`Create a clinical handover note using ISBAR: 566 567I â Identify: 568Record patient name, age, ward/bed, and handing-over clinician â as stated. 569 570S â Situation: 571Document the current clinical situation and reason for handover â only as described. 572 573B â Background: 574Record admitting diagnosis, relevant history, key events, medications, and allergies â only as stated. 575 576A â Assessment: 577Document current clinical status, vital signs, and outstanding concerns â only as explicitly described. 578 579R â Recommendation: 580Record pending tasks, monitoring required, escalation criteria, and pending results â only as stated.`},{label:"MDT Note / Team Care Conference",category:"clinical note",description:"Multidisciplinary discussion, agreed management plan & follow-up",prompt:`Create a multidisciplinary team meeting note with the following structure: 581 582Meeting Details: 583Record the date, location, and attendees by name and discipline â as documented. 584 585Patient Summary: 586State the patient's diagnosis, admission details, and reason for MDT discussion â only as described. 587 588Discipline Updates: 589Document the contribution from each discipline â medical, nursing, allied health, social work â only as explicitly stated. 590 591Goals of Care Discussion: 592Record goals-of-care discussion â only if explicitly documented. 593 594Agreed Management Plan: 595Document decisions and actions agreed â with responsible clinician â only as stated. 596 597Follow-Up & Review: 598Record the next MDT date and outstanding actions â only as discussed.`},{label:"ED Triage Note",category:"emergency",description:"Triage category, vital signs, initial impressions & nurse-initiated actions",prompt:`Create an ED triage note with the following structure: 599 600Date, Time & Triage Category: 601Record as documented. 602 603Mode of Arrival: 604State how the patient arrived â as stated. 605 606Chief Complaint: 607One sentence â the patient's primary concern in their own words. 608 609Triage Assessment: 610Document vital signs, visible injury or distress, pain score, and initial observations â only as explicitly recorded by the triaging nurse. 611 612Allergies & Medications: 613Record â only if stated at triage. 614 615Triage Nurse Impression: 616State only the impression documented. Do not add clinical interpretations. 617 618Initial Actions: 619Record any immediate nurse-initiated actions â only as documented.`},{label:"ED Medical Assessment Note",category:"emergency",description:"Presenting complaint, examination, investigations, impression & disposition",prompt:`Create an ED medical assessment note with the following structure: 620 621Date, Time & Clinician: 622Record as stated. 623 624Presenting Complaint: 625One to two sentences â as stated by the patient or documented at triage. 626 627History of Presenting Illness: 628Document onset, character, severity, duration, associated symptoms â only as explicitly stated. 629 630Past Medical History / Medications / Allergies: 631List only what was mentioned. 632 633Examination: 634Vital signs and focused examination â document only findings explicitly described. 635 636Investigations: 637List investigations ordered and results reviewed â only as discussed. 638 639Clinical Impression: 640Record only the working diagnosis or differential stated by the treating clinician. 641 642Management: 643Document interventions and clinical decisions â only as described. 644 645Disposition: 646State the outcome â as explicitly documented.`},{label:"ED Nursing Assessment Note",category:"emergency",description:"Vital signs, nursing findings, interventions & team communication",prompt:`Create an ED nursing assessment note with the following structure: 647 648Date, Time & Nurse: 649Record as stated. 650 651Patient Status: 652Document current condition and changes since triage â only as observed and stated. 653 654Vital Signs & Observations: 655Record with time â only as documented. 656 657Pain Assessment: 658Record pain score, location, and character â only as stated. 659 660Nursing Assessment Findings: 661Document relevant nursing findings â only as described. 662 663Interventions: 664Record nursing interventions â IV access, medications, monitoring, wound care â only as documented. 665 666Patient Response: 667Note response to treatment â only as observed and stated. 668 669Communication to Medical Team: 670Record communication and instructions received â only if documented.`}
670,{label:"ED Disposition Summary",category:"emergency",description:"ED diagnosis, treatment summary, discharge instructions & follow-up plan",prompt:`Create an ED disposition and discharge summary with the following structure: 671 672ED Diagnosis: 673State only the diagnosis or impression explicitly documented at disposition. 674 675Summary of Assessment & Treatment: 676Briefly summarise investigations, treatments, and decisions â only as documented. 677 678Disposition Decision: 679Record the outcome â discharge, admission, transfer, or observation â as explicitly stated. 680 681Discharge Medications: 682List any medications prescribed at discharge â only as stated. 683 684Discharge Instructions: 685Record specific instructions â only as documented. 686 687Safety Netting & Return Criteria: 688Document red-flag symptoms and return-to-ED advice â only if explicitly provided. 689 690Follow-Up: 691State the follow-up plan â only as arranged.`},{label:"Nursing Handover Note â ED",category:"handover",description:"ISBAR format ED nursing shift handover",prompt:`Create an ED nursing shift handover note using ISBAR: 692 693I â Identify: 694Record patient name, age, bay/bed, and handing-over nurse â as stated. 695 696S â Situation: 697Document current clinical situation and reason for handover â only as described. 698
699B â Background: 700Record presenting complaint, relevant history, treatments given this shift, and allergies â only as stated. 701 702A â Assessment: 703Document current vital signs and outstanding concerns â only as explicitly described. 704 705R â Recommendation: 706Record pending tasks, monitoring, escalation criteria â only as stated.`},{label:"Trauma Assessment Note",category:"emergency",description:"Primary & secondary survey, injuries identified, resuscitation & disposition",prompt:`Create a trauma assessment note with the following structure: 707 708Activation Details: 709Record trauma activation level, mechanism of injury, and patient age and sex â as documented. 710 711Primary Survey (ABCDE): 712Document each element â only as explicitly assessed and described. 713 714Vital Signs & GCS: 715Record initial and subsequent values â only as documented. 716 717Secondary Survey: 718Document head-to-toe findings â only as explicitly described. 719 720Investigations: 721List bloods, imaging, and FAST results â only as ordered and reviewed. 722 723Injuries Identified: 724Record only injuries explicitly documented. 725 726Resuscitation & Management: 727Document interventions and decisions â only as stated. 728 729Trauma Team Communication: 730Record specialist input â only if explicitly mentioned. 731 732Disposition: 733State the disposition decision â as documented.`},{label:"Resuscitation / Code Blue Record",category:"emergency",description:"Event timeline, interventions, cardiac rhythm & post-resuscitation plan",prompt:`Create a resuscitation event or Code Blue / MET call record with the following structure: 734 735Event Details: 736Record date, time of activation, location, and call type â as documented. 737 738Patient Condition at Activation: 739State the presenting condition and vital signs â only as documented. 740 741Team Present: 742List responding team members and roles â only as recorded. 743 744Timeline of Events: 745Document the sequence of interventions with times â CPR, defibrillation, medications, airway â only as explicitly recorded. 746 747Rhythm: 748Record cardiac rhythm at each check â only as documented. 749 750Medications Given: 751List drugs, doses, and times â only as recorded. 752 753Outcome: 754State the outcome and time â as explicitly documented. 755 756Post-Resuscitation Plan: 757Record agreed post-resuscitation management â only as stated.`},{label:"Consent Documentation Note",category:"procedure",description:"Capacity assessment, risks discussed, consent type & clinician sign-off",prompt:`Create a procedure consent documentation note with the following structure: 758 759Patient Details & Decision-Making Capacity: 760Record patient name and the clinician's capacity assessment â as explicitly stated. 761 762Procedure: 763State the procedure name â as documented. 764 765Indication: 766Record the clinical indication â as stated. 767 768Risks, Benefits & Alternatives Discussed: 769Document only specific items explicitly discussed with the patient. 770 771Patient Questions: 772Record questions raised and responses â only if documented. 773 774Consent Given: 775State type â written, verbal, or by SDM â and who agreed â as documented. 776 777Interpreter Used: 778Note if used â only if explicitly stated. 779 780Clinician Sign-Off: 781Record name, role, and date â as documented.`},{label:"Initial Physiotherapy Assessment",category:"allied health",description:"Presenting complaint, objective assessment, problem list, goals & treatment",prompt:`Create a community physiotherapy initial assessment note with the following structure: 782 783Referral & Reason: 784Record referral source and reason â as documented. 785 786Presenting Complaint: 787Document primary concern â only as stated. 788 789History of Presenting Condition: 790Record onset, mechanism, aggravating and easing factors, pain score, prior treatment, and functional impact â only as explicitly stated. 791 792Relevant Medical & Surgical History: 793List only what was mentioned. 794 795Social & Occupational History: 796Record living situation, employment, and daily activities â only if mentioned. 797 798Objective Assessment: 799Document posture, ROM with values if stated, strength, neurological screen, special tests and results, gait, and functional tests â only as performed and described. 800 801Outcome Measures: 802Record validated tools and scores â only as stated. 803 804Problem List: 805List only impairments and restrictions identified. 806 807Goals: 808Document goals set collaboratively â only as stated. 809 810Treatment Provided This Session: 811Record interventions delivered â only as described. 812 813Home Exercise Programme: 814List exercises with sets, reps, and frequency â only if prescribed. 815 816Plan & Review Frequency:
817State the agreed plan â only as discussed.`},{label:"Physiotherapy Treatment / Progress Note",category:"allied health",description:"Subjective update, objective findings, treatment delivered & next session plan",prompt:`Create a physiotherapy treatment and progress note with the following structure: 818 819Date & Clinician: 820Record as stated. 821 822Subjective Update: 823Document reported symptoms, changes since last session, and HEP compliance â only as stated. 824 825Objective Findings: 826Record reassessment findings â ROM, strength, pain, function â only as measured and described. 827 828Progress Towards Goals: 829Document measurable progress â only as recorded. 830 831Treatment Delivered: 832Record interventions provided â only as described. 833 834HEP Update: 835Note any changes â only if discussed. 836 837Plan & Next Session: 838State the plan for the next session â only as discussed.`},{label:"Physiotherapy Discharge / Closure Note",category:"allied health",description:"Discharge reason, goals achieved, outcomes & ongoing home programme",prompt:`Create a physiotherapy discharge or closure note with the following structure: 839 840Discharge Date & Reason: 841Record date and reason â goal attainment, patient choice, non-attendance, or other â as stated. 842 843Summary of Presentation: 844Briefly state the presenting complaint and goals â only as documented. 845 846Treatment Provided: 847Summarise course of treatment and key interventions â only as stated. 848 849Outcome at Discharge: 850Document patient status using objective measures â only as recorded. 851 852Goals Achieved: 853State which goals were and were not achieved â only as documented. 854 855Discharge HEP: 856List the ongoing home programme â only if stated. 857 858Recommendations & Referrals: 859Record onward referrals â only as discussed.`},{label:"Home Exercise Programme (HEP)",category:"allied health",description:"Exercise list with sets, reps, frequency, load & precautions",prompt:`Create a patient home exercise programme with the following structure: 860 861Programme Goal: 862State the functional goal â only as described. 863 864Exercises: 865For each exercise prescribed, document: 866- Exercise name 867- Technique cues â only as stated 868- Sets, repetitions, and frequency â only as prescribed 869- Resistance or load â only if stated 870- Progression criteria â only if discussed 871 872Precautions: 873List movements to avoid â only as explicitly stated. 874 875Review Date: 876Record planned review â only if stated.`},{label:"Physiotherapy Outcome Measure Report",category:"allied health",description:"Validated tool scores at baseline and follow-up with clinician interpretation",prompt:`Create a physiotherapy outcome measure report with the following structure: 877 878Outcome Measure Used: 879State the validated tool â PSFS, DASH, Oxford Knee Score, Oxford Hip Score, Oswestry, or other â only as performed. 880 881Score at Initial Assessment: 882Record baseline score â only as documented. 883 884Score at Reassessment / Discharge: 885Record follow-up score and date â only if measured. 886 887Clinician Interpretation: 888Record only the clinician's stated interpretation. 889 890Ongoing Monitoring Plan: 891Note plan for further measurement â only if discussed.`},{label:"Physiotherapy Referral Letter",category:"correspondence",description:"Physiotherapy summary, clinical question & onward referral details",prompt:`Create a physiotherapy referral letter with the following structure: 892 893Date & Recipient: 894Record date, recipient's name, role, and service â as stated. 895 896Patient Details: 897Document name, date of birth, and contact â as provided. 898 899Reason for Referral: 900State the clinical reason â only as documented. 901 902Summary of Physiotherapy Management: 903Briefly describe findings, treatment, and outcomes â only as stated. 904 905Clinical Question or Request: 906State the specific request â only as documented. 907 908Clinician Sign-Off: 909Include name, AHPRA number, and date â as documented.`},{label:"Orthopaedic APC Assessment Note",category:"musculoskeletal",description:"History, examination, imaging review, impression & management pathway",prompt:`Create an orthopaedic advanced practice clinic initial assessment note with the following structure: 910 911Referral Source & Clinical Question: 912State referral source and specific orthopaedic question â as documented. 913 914History of Presenting Condition: 915Document symptom onset, mechanism, prior imaging, previous management, and current functional status â only as explicitly stated. 916 917Relevant Medical, Medication & Allergy History: 918List only what was mentioned. 919 920Objective Examination: 921Record inspection, palpation, ROM with degrees if stated, strength grading, neurovascular assessment, special tests and results â only as performed and described. 922 923Imaging Review: 924Summarise findings from imaging discussed â only as stated. 925 926Outcome Measures: 927Record validated tools and scores â only if performed. 928 929Clinical Impression: 930State only the musculoskeletal diagnosis or differential explicitly stated by the APC clinician. 931 932Management Plan: 933Document the agreed pathway â conservative, injection, imaging, or surgical referral â only as stated. 934 935Follow-Up:
936Record the review plan â only as discussed.`},{label:"Orthopaedic APC Review Note",category:"musculoskeletal",description:"Interval history, reassessment findings & updated management plan",prompt:`Create an orthopaedic APC review or follow-up note with the following structure: 937 938Reason for Review: 939State the purpose â as documented. 940 941Interval History: 942Document reported progress and response to management â only as stated. 943 944Objective Reassessment: 945Record findings â ROM, strength, functional tests, outcome scores â only as measured and described. 946 947Investigation Results: 948Summarise results since last visit â only as stated. 949 950Revised Clinical Impression: 951State any diagnosis change â only as explicitly documented. 952 953Updated Plan: 954Record management changes â only as discussed. 955 956Follow-Up: 957State next review or discharge plan â only as documented.`},{label:"Imaging Request / Interpretation Note",category:"musculoskeletal",description:"Modality, clinical indication, findings & management decision",prompt:`Create an imaging request or interpretation note with the following structure: 958 959Requesting Clinician: 960Record name and role â as stated. 961 962Imaging Modality Requested: 963State the specific modality and body region â only as explicitly stated. 964 965Clinical Indication: 966Document the clinical reason and specific question â exactly as stated. 967 968Relevant History: 969Include prior imaging and clinical findings â only as mentioned. 970 971Imaging Findings (if interpretation): 972Document only findings explicitly described. 973 974Clinical Correlation: 975Record only the clinician's stated interpretation. 976 977Management Decision Based on Imaging: 978Record management change â only as stated.`},{label:"Surgical Referral Letter â Orthopaedic",category:"correspondence",description:"Clinical summary, functional impact, surgical question & urgency",prompt:`Create an orthopaedic surgical referral letter with the following structure: 979 980Date & Recipient: 981Record date and receiving surgeon's name, specialty, and address â as stated. 982 983Patient Details: 984Document name, date of birth, and contact â as provided. 985 986Reason for Referral: 987State the indication for surgical review â as explicitly documented. 988 989Clinical Summary: 990Summarise presenting condition, examination, imaging, and conservative management â only as stated. 991 992Current Functional Impact: 993Record functional limitations â only as described. 994 995Specific Surgical Question: 996State the question â only as documented. 997 998Urgency: 999State urgency â only if explicitly stated. 1000 1001Clinician Sign-Off: 1002Include name, AHPRA number, and date â as documented.`},{label:"Orthopaedic Outcome Measure Report",category:"musculoskeletal",description:"Baseline and follow-up orthopaedic scores with clinician interpretation",prompt:`Create an orthopaedic outcome measure report with the following structure: 1003 1004Outcome Measure Used: 1005State the validated tool â Oxford Knee Score, Oxford Hip Score, PROMS, KOOS, HOOS, or other â only as performed. 1006 1007Score at Initial Assessment: 1008Record baseline score â only as documented. 1009 1010Score at Follow-Up: 1011Record follow-up score and date â only if measured. 1012 1013Clinician Interpretation: 1014Record only the clinician's stated interpretation. 1015 1016Management Decision Based on Score: 1017Record any management change â only as stated.`},{label:"Injection Procedure Note",category:"procedure",description:"Injection agent & site, technique, immediate response & post-procedure advice",prompt:`Create a joint or soft tissue injection procedure note with the following structure: 1018 1019Date, Time & Clinician: 1020Record as stated. 1021 1022Indication: 1023State the clinical indication â only as documented. 1024 1025Consent: 1026Record whether informed consent was obtained â only as stated. 1027 1028Injection Details: 1029Document type, agent, dose, diluent, and volume â only as explicitly stated. 1030 1031Site & Approach: 1032Record anatomical site, patient position, and approach â only as described. 1033 1034Guidance Used: 1035State whether ultrasound or landmark guidance was used â only if mentioned. 1036 1037Procedure Description: 1038Describe technique â only as stated. 1039 1040Immediate Response: 1041Document patient's immediate response â only as observed and stated. 1042 1043Post-Procedure Instructions: 1044Record advice given â only as stated. 1045 1046Follow-Up: 1047State planned review â only as documented.`},{label:"RADAR Rapid Assessment Note",category:"geriatrics",description:"Deterioration trigger,
1047clinical assessment, impression & acute management",prompt:`Create a RADAR clinician rapid assessment note with the following structure: 1048 1049Activation Details: 1050Record date, time, location, and trigger â as documented. 1051 1052Reason for Rapid Review: 1053State the clinical concern â only as described. 1054 1055Presenting Deterioration: 1056Document the acute change from baseline â only as stated. 1057 1058Baseline Functional Status: 1059Record pre-morbid function and living situation â only as explicitly stated. 1060 1061Clinical Assessment: 1062Document vital signs, delirium screening result, targeted examination, and relevant investigations â only as described. 1063 1064Medication Review: 1065Note any flagged medications â only if discussed. 1066 1067Clinical Impression: 1068State only the diagnosis or concern explicitly documented. 1069 1070Acute Management: 1071Document interventions and decisions â only as stated. 1072 1073Disposition: 1074State the disposition decision â as documented.`},{label:"RADAR Nurse-Initiated Assessment",category:"geriatrics",description:"Escalation trigger, observations, delirium screen & ISBAR communication",prompt:`Create a RADAR nurse-initiated deterioration escalation record with the following structure: 1075 1076Date, Time & Nurse: 1077Record as stated. 1078 1079Patient Baseline: 1080Document usual cognitive and functional status â only as known and stated. 1081 1082Trigger for Escalation: 1083Record the specific clinical concern â only as described. 1084 1085Observations: 1086Document vital signs and any NEWS2 or BETWEEN score â only as recorded. 1087 1088Delirium Screening: 1089Record result â only if performed and documented. 1090 1091Nursing Assessment: 1092Document relevant findings â only as explicitly described. 1093 1094Actions Taken: 1095Record nurse-initiated actions â only as documented. 1096 1097Communication to Medical Team: 1098Record ISBAR communication and response â only as documented. 1099 1100Outcome: 1101State the outcome â only as documented.`},{label:"RADAR Disposition Note",category:"geriatrics",description:"Assessment summary, agreed management plan & disposition decision",prompt:`Create a post-RADAR disposition note with the following structure: 1102 1103Assessment Summary: 1104Briefly state the acute presentation and key findings â only as documented. 1105 1106Diagnosis / Clinical Impression: 1107Record only the diagnosis or concern explicitly stated. 1108 1109Agreed Management Plan: 1110Document management decisions following RADAR â only as stated. 1111 1112Disposition Decision: 1113State the outcome â continue ward care, step-up, transfer, or discharge â as explicitly documented. 1114 1115Escalation Criteria: 1116Record agreed thresholds â only if documented. 1117 1118Family / Carer Communication: 1119Note any communication â only if explicitly documented. 1120 1121Follow-Up Review: 1122State timing of next review â only as discussed.`},{label:"Vital Signs Observation Chart Note",category:"nursing",description:"Observations, early warning score, changes from previous & actions taken",prompt:`Create a vital signs observation chart entry with the following structure: 1123 1124Date & Time: 1125Record as documented. 1126 1127Observations: 1128Record all vital signs â temperature, heart rate, blood pressure, respiratory rate, oxygen saturation, and conscious state â as documented. 1129 1130Early Warning Score: 1131Record NEWS2, BETWEEN, or equivalent â only if calculated and documented. 1132 1133Comparison to Previous: 1134Note any change from previous observations â only as stated. 1135 1136Symptom Correlation: 1137Record patient-reported symptoms at the time â only as stated. 1138 1139Action Taken: 1140Document any clinical action â only as recorded. 1141 1142Clinician Notification:
1143Record whether and when a clinician was notified â only if documented.`},{label:"Comprehensive Geriatric Assessment (CGA)",category:"geriatrics",description:"Functional, cognitive, mood, social & frailty assessment with recommendations",prompt:`Create a comprehensive geriatric assessment note with the following structure: 1144 1145Referral & Reason: 1146State referral source and primary reason â as documented. 1147 1148Presenting Problems: 1149List patient's current concerns â as stated. 1150 1151Functional Assessment: 1152Document ADL and IADL capacity, mobility aids, falls history, and functional scores â only as explicitly stated. 1153 1154Cognitive Assessment: 1155Record screening tool, score, and impression â only if assessed and documented. 1156 1157Mood & Psychological: 1158Document screening results and concerns â only as stated. 1159 1160Social Circumstances: 1161Record living situation, carer support, community services, and legal matters â only as mentioned. 1162 1163Nutritional Status: 1164Include weight, BMI, weight change, and screening results â only if documented. 1165 1166Medications: 1167List medications and deprescribing decisions â only as discussed. 1168 1169Physical Examination: 1170Document only findings explicitly described. 1171 1172Geriatric Syndromes: 1173List only syndromes explicitly identified. 1174 1175Frailty Assessment: 1176Record tool and result â only if performed and stated. 1177 1178Formulation & Recommendations: 1179State only the formulation and recommendations explicitly documented by the geriatrician. 1180 1181Follow-Up & Referrals: 1182Record review plan and referrals as discussed.`},{label:"Geriatric Inpatient Progress Note",category:"geriatrics",description:"Daily SOAP update with MDT input and discharge planning progress",prompt:`Create a geriatric inpatient daily progress note with the following structure: 1183 1184Date, Time & Clinician: 1185Record as stated. 1186 1187Subjective: 1188Document reported symptoms and overnight events â only as stated. 1189 1190Objective: 1191Record vital signs and focused examination findings â only as explicitly described. 1192 1193Investigations: 1194Summarise results reviewed â only as discussed. 1195 1196Assessment: 1197Record clinical impression and progress â only as stated. 1198 1199Plan: 1200Document management decisions and medication changes â only as stated. 1201 1202MDT Update: 1203Note allied health or nursing updates â only if mentioned. 1204 1205Discharge Planning: 1206Record progress â only if discussed.`},{label:"Falls Risk Assessment",category:"geriatrics",description:"Falls history, risk score, intrinsic & extrinsic factors & prevention plan",prompt:`Create a falls risk assessment note with the following structure: 1207 1208Reason for Assessment: 1209Document the trigger â as stated. 1210 1211Falls History: 1212Record number of falls, circumstances, injuries, and fear of falling â only as explicitly stated. 1213 1214Falls Risk Tool: 1215Record tool used and score â only if performed and documented. 1216 1217Intrinsic Risk Factors: 1218List only factors explicitly identified â cognitive impairment, medications, weakness, visual impairment, continence issues, or other. 1219 1220Extrinsic & Environmental Risk Factors: 1221Record only those explicitly discussed. 1222 1223Current Mobility Aids: 1224Document aids used â only as stated. 1225 1226Interventions Agreed: 1227List falls prevention interventions â only as documented. 1228 1229Patient & Carer Education: 1230Record education provided â only as stated. 1231 1232Referrals: 1233Note referrals for falls prevention â only if mentioned.`},{label:"Cognitive Assessment Note",category:"geriatrics",description:"Screening tool & score, domain findings, differential & management plan",prompt:`Create a cognitive assessment note with the following structure: 1234 1235Reason for Assessment: 1236Document indication â as stated. 1237 1238Informant History: 1239Record collateral history â only as explicitly provided. 1240 1241Cognitive Screening Tool: 1242State tool and total score â MMSE, MoCA, RUDAS, AMT â only if performed and documented. 1243 1244Domain Results: 1245Record subscores or domain findings â only if stated. 1246 1247Functional Cognitive Impact: 1248Document functional capacity related to cognition â only as described. 1249 1250Behavioural & Psychological Symptoms: 1251Record BPSD â only if explicitly discussed. 1252 1253Driving & Safety: 1254Note concerns raised â only if explicitly documented. 1255 1256Differential Diagnosis: 1257Record only diagnoses or differentials explicitly stated. 1258 1259Management Plan: 1260Document agreed management â only as explicitly stated.`},{label:"Goals of Care / ACP Note",category:"geriatrics",description:"Patient wishes, capacity, treatment preferences & DNACPR/NFR documentation",prompt:`Create a goals of care or advance care planning note with the following structure: 1261 1262Date, Clinician & Participants: 1263Record the date, clinician, and participants â as documented. 1264 1265Reason for Discussion: 1266State the clinical context â only as documented. 1267 1268Patient's Expressed Wishes & Values: 1269Record stated goals and preferences â in their own words where possible â only as explicitly stated. 1270 1271Decision-Making Capacity: 1272Document the clinician's assessment â only as explicitly stated. 1273 1274Substitute Decision-Maker: 1275Record SDM details â only if identified and documented. 1276
1277Medical Treatment Preferences Discussed: 1278Record only specific preferences discussed and the agreed position. 1279 1280DNACPR / NFR Order: 1281If documented, record the order, rationale, and participants. 1282 1283Review Date: 1284State when the plan will be reviewed â only if discussed.`},{label:"Aged Care Referral Letter",category:"correspondence",description:"Clinical summary, functional & cognitive status & aged care referral goals",prompt:`Create an aged care referral letter with the following structure: 1285 1286Date & Recipient: 1287Record date and receiving organisation or assessor â as stated. 1288 1289Patient Details: 1290Document name, date of birth, address, and identifier â as provided. 1291 1292Reason for Referral: 1293State the specific aged care need â only as documented. 1294 1295Clinical Summary: 1296Summarise diagnoses, functional status, cognitive status, and social circumstances â only as explicitly stated. 1297 1298Current Services in Place: 1299List existing supports â only as mentioned. 1300 1301Carer Situation: 1302Document carer capacity and stress â only if stated. 1303 1304Goals of the Referral: 1305State what the referral aims to achieve â only as documented. 1306 1307Clinician Contact Details: 1308Include name, role, and phone â as stated.`},{label:"Geriatric Discharge Summary",category:"summary",description:"Admission to discharge with medications, functional status & follow-up plan",prompt:`Create a geriatric inpatient discharge summary with the following structure: 1309 1310Admission Details: 1311Record admission date, ward, admitting diagnosis, and reason â as stated. 1312 1313Hospital Course: 1314Summarise key clinical events, procedures, and MDT involvement â only as described. 1315 1316Active Problems at Discharge: 1317List diagnoses and issues â only as documented. 1318 1319Discharge Medications: 1320List all medications with dose and frequency â as stated. Note changes from admission. 1321 1322Pending Results: 1323List investigations awaited â only if stated. 1324 1325Functional Status at Discharge: 1326Record functional level and equipment needs â only as documented. 1327 1328Discharge Destination: 1329State where the patient was discharged â as documented. 1330 1331Follow-Up Plan: 1332Record appointments and community services arranged â only as stated.`},{label:"Continence / Pressure Injury Assessment",category:"geriatrics",description:"Continence type or wound staging, contributing factors & management plan",prompt:`Create a continence or pressure injury assessment note with the following structure: 1333 1334Assessment Type: 1335State whether continence, pressure injury, or combined â as documented. 1336 1337Continence Assessment (if applicable): 1338Document type, frequency, severity, and impact â only as explicitly stated. Record tool used and score. 1339 1340Pressure Injury Assessment (if applicable): 1341Record location, stage, dimensions, wound bed, exudate, and surrounding skin â only as explicitly described. 1342 1343Contributing Factors: 1344List only factors explicitly identified. 1345 1346Current Management: 1347Record interventions in place â only as described. 1348 1349Plan & Goals: 1350Document the agreed plan â only as stated. 1351 1352Referrals: 1353Note specialist referrals â only if mentioned. 1354 1355Review Date: 1356State planned review â only as documented.`},{label:"Medical Admissions Note â MAPU",category:"general medicine",description:"Presenting illness, examination, diagnosis, acute plan & escalation criteria",prompt:`Create a MAPU medical admission note with the following structure: 1357 1358Admission Details: 1359Record date, time, admission source, and presenting complaint â as documented. 1360 1361History of Presenting Illness: 1362Document symptom onset, progression, severity, associated features â only as explicitly stated. 1363 1364Past Medical & Surgical History: 1365List only what was mentioned. 1366 1367Medications & Allergies: 1368Record as stated. Note recent changes. 1369 1370Social History: 1371Include living situation, smoking, alcohol, and functional baseline â only if mentioned. 1372 1373Examination: 1374Vital signs and system examination â document only findings explicitly described. 1375 1376Investigations: 1377List results and tests ordered â only as discussed. 1378 1379Working Diagnosis / Differential: 1380Record only the diagnosis or differential documented by the admitting clinician. 1381 1382Acute Management Plan: 1383Document interventions, medications, and monitoring â only as stated. 1384 1385Escalation Plan: 1386Include escalation criteria â only if explicitly discussed.`},{label:"Gen Med Inpatient Progress Note",category:"general medicine",description:"Daily SOAP format update with discharge planning progress",prompt:`Create a general medicine inpatient progress note with the following structure: 1387 1388Date, Time & Clinician: 1389Record as stated. 1390 1391Subjective: 1392Document reported symptoms and overnight events â only as stated. 1393 1394Objective: 1395Record vital signs and focused findings â only as explicitly described. 1396 1397Investigations:
1398Summarise results reviewed â only as discussed. 1399 1400Assessment: 1401Record clinical impression and progress â only as stated. 1402 1403Plan: 1404Document management decisions and medication changes â only as stated. 1405 1406Discharge Planning Update: 1407Note progress on discharge planning â only if discussed.`},{label:"Nursing Admission Assessment â MAPU",category:"nursing",description:"Nursing history, physical assessment, risk screens & discharge planning needs",prompt:`Create a nursing admission assessment for a MAPU inpatient with the following structure: 1408 1409Admission Mode & Source: 1410Document how and where the patient was admitted â as stated. 1411 1412Presenting Complaint: 1413Record in the patient's own words â only as stated. 1414 1415Nursing Health History: 1416Document relevant medical history, medications, allergies, and functional history â only as explicitly provided. 1417 1418Physical Assessment: 1419Record vital signs, neurological observations, skin integrity, pain score â only as described. 1420 1421Cognitive & Communication Assessment: 1422Document orientation, communication needs â only as observed or stated. 1423 1424Nutritional Screening: 1425Record tool and result â only if performed. 1426 1427Falls Risk: 1428Record score â only if assessed and documented. 1429 1430Pressure Injury Risk: 1431Record risk score and skin inspection â only as documented. 1432 1433Social & Discharge Planning Needs: 1434Note initial discharge concerns â only if raised at admission.`},{label:"Discharge Summary â MAPU",category:"summary",description:"Admission to discharge with medications, pending results & follow-up plan",prompt:`Create a MAPU inpatient discharge summary with the following structure: 1435 1436Admission Details: 1437Record admission date, admitting diagnosis, and reason â as stated. 1438 1439Hospital Course: 1440Summarise key clinical events and decisions â only as described. 1441 1442Discharge Diagnosis: 1443Record only the diagnosis explicitly stated at discharge. 1444 1445Discharge Medications: 1446List medications with dose and frequency â as stated. Note changes. 1447 1448Pending Investigations: 1449List results awaited â only if stated. 1450 1451Follow-Up Instructions: 1452Include appointments, restrictions, and return criteria â only as stated. 1453 1454GP Communication: 1455Record key information communicated to the GP â only if mentioned.`},{label:"Nursing Handover Note â MAPU",category:"handover",description:"ISBAR format nursing shift handover for MAPU patients",prompt:`Create a nursing shift handover note using ISBAR: 1456 1457I â Identify: 1458Record patient name, age, ward/bed, and handing-over nurse â as stated. 1459 1460S â Situation: 1461Document current situation and reason for handover â only as described. 1462
1463B â Background: 1464Record admitting diagnosis, key events this shift, medications, and allergies â only as stated. 1465 1466A â Assessment: 1467Document current vital signs and outstanding concerns â only as explicitly described. 1468 1469R â Recommendation: 1470Record pending tasks, monitoring, and escalation criteria â only as stated.`},{label:"Allied Health Referral Note",category:"correspondence",description:"Clinical reason, patient details, urgency & contact for allied health referral",prompt:`Create an allied health internal referral note with the following structure: 1471 1472Referring Clinician & Date: 1473Record as stated. 1474 1475Receiving Discipline: 1476State the allied health profession â as documented. 1477 1478Patient Details: 1479Record name, ward, date of birth, and admission diagnosis â as provided. 1480 1481Reason for Referral: 1482State the specific clinical reason and question â only as documented. 1483 1484Relevant Clinical Information: 1485Include medical history, functional status, cognitive status â only as explicitly stated. 1486 1487Urgency: 1488State urgency â only if documented. 1489 1490Contact for Queries: 1491Record referring clinician's contact â as documented.`},{label:"Goals of Care / ACP Note â Gen Med",category:"general medicine",description:"Patient wishes, capacity, treatment preferences & DNACPR/NFR documentation",prompt:`Create a goals of care or ACP note for a general medicine inpatient with the following structure: 1492 1493Date, Clinician & Participants: 1494Record as documented. 1495 1496Reason for Discussion: 1497State the clinical context â only as documented. 1498 1499Patient's Expressed Wishes & Values: 1500Record stated goals and preferences â only as explicitly stated. 1501 1502Decision-Making Capacity: 1503Document clinician's assessment â only as explicitly stated. 1504 1505Substitute Decision-Maker: 1506Record SDM details â only if identified and documented. 1507
1508Medical Treatment Preferences Discussed: 1509Record only specific preferences discussed and the agreed position. 1510 1511DNACPR / NFR Order: 1512If documented, record the order, rationale, and participants. 1513 1514Review Date: 1515State when the plan will be reviewed â only if discussed.`},{label:"Acute Medical Admission Note â AMU",category:"general medicine",description:"Presenting illness, examination, differentials, diagnosis & management plan",prompt:`Create an AMU acute medical admission note with the following structure: 1516 1517Admission Details: 1518Record date, time, admission source, and presenting complaint â as documented. 1519 1520History of Presenting Illness: 1521Document symptom onset, character, severity, duration, associated symptoms â only as explicitly stated. 1522 1523Past Medical & Surgical History: 1524List only what was mentioned. 1525 1526Medications & Allergies: 1527Record as stated. Note recent changes. 1528 1529Social History: 1530Include living situation, smoking, alcohol, and functional baseline â only if mentioned. 1531 1532Examination: 1533Document vital signs and systematic examination findings â only as explicitly described. 1534 1535Investigations: 1536List results and tests ordered â only as discussed. 1537 1538Clinical Reasoning & Differentials: 1539Record differential and reasoning â only as stated. 1540 1541Working Diagnosis: 1542State only the diagnosis explicitly documented. 1543 1544Acute Management Plan: 1545Record interventions, medications, and monitoring â only as stated. 1546 1547Senior Review: 1548Document registrar or consultant input â only if mentioned.`},{label:"Senior Medical Review Note â AMU",category:"general medicine",description:"Senior clinical impression, updated management plan & team instructions",prompt:`Create a senior medical review note with the following structure: 1549 1550Date, Time & Clinician: 1551Record as stated. 1552 1553Reason for Review: 1554State whether scheduled review, escalation, or ward round â as documented. 1555 1556Clinical Summary: 1557Briefly summarise the presentation and management â only as stated. 1558 1559Examination Findings: 1560Record only findings explicitly described. 1561 1562Investigations: 1563Summarise results reviewed â only as discussed. 1564 1565Clinical Impression: 1566State only the diagnosis or revised impression explicitly documented. 1567 1568Management Plan: 1569Document the senior clinician's plan â only as stated. 1570 1571Communication to Team: 1572Note instructions given â only if documented.`},{label:"Discharge Summary â AMU",category:"summary",description:"Admission to discharge with medications, pending results & follow-up plan",prompt:`Create an AMU inpatient discharge summary with the following structure: 1573 1574Admission Details: 1575Record admission date, admitting diagnosis, and reason â as stated. 1576 1577Hospital Course: 1578Summarise key clinical events and decisions â only as described. 1579 1580Discharge Diagnosis: 1581Record only the diagnosis explicitly stated at discharge. 1582 1583Discharge Medications: 1584List medications with dose and frequency â as stated. Note changes. 1585 1586Pending Investigations: 1587List results awaited â only if stated. 1588 1589Follow-Up Instructions: 1590Include appointments, restrictions, and return criteria â only as stated. 1591 1592GP Communication: 1593Record key information communicated â only if mentioned.`},{label:"Nursing Admission Assessment â AMU",category:"nursing",description:"Nursing history, physical assessment, risk screens & discharge planning needs",prompt:`Create a nursing admission assessment for an AMU inpatient with the following structure: 1594 1595Admission Mode & Source: 1596Document how and where the patient was admitted â as stated. 1597 1598Presenting Complaint: 1599Record in the patient's own words â only as stated. 1600 1601Nursing Health History: 1602Document medical history, medications, allergies, and functional history â only as explicitly provided. 1603 1604Physical Assessment: 1605Record vital signs, neurological observations, skin integrity, pain score â only as described. 1606 1607Cognitive & Communication Assessment: 1608Document orientation and communication needs â only as observed or stated. 1609 1610Nutritional Screening: 1611Record tool and result â only if performed. 1612 1613Falls Risk: 1614Record score â only if assessed and documented. 1615 1616Pressure Injury Risk: 1617Record risk score and skin inspection â only as documented. 1618 1619Social & Discharge Planning Needs: 1620Note initial discharge concerns â only if raised at admission.`},{label:"Nursing Handover Note â AMU",category:"handover",description:"ISBAR format nursing shift handover for AMU patients",prompt:`Create a nursing shift handover note using ISBAR: 1621 1622I â Identify: 1623Record patient name, age, ward/bed, and handing-over nurse â as stated. 1624 1625S â Situation: 1626Document current situation and reason for handover â only as described. 1627
1628B â Background: 1629Record admitting diagnosis, key events this shift, medications, and allergies â only as stated. 1630 1631A â Assessment: 1632Document current vital signs and outstanding concerns â only as explicitly described. 1633 1634R â Recommendation: 1635Record pending tasks, monitoring, and escalation criteria â only as stated.`},{label:"Medication Chart Review Note â AMU",category:"review",description:"Reconciliation, discrepancies, high-risk medication review & prescriber communication",prompt:`Create a medication chart review or medicines reconciliation note for an AMU inpatient with the following structure: 1636 1637Date & Reviewing Clinician: 1638Record as stated. 1639 1640Reason for Review: 1641State the indication â admission reconciliation, polypharmacy, renal adjustment, or other â as documented. 1642 1643Pre-Admission Medication List: 1644Record medications as verified â note source. Flag discrepancies. 1645 1646Discrepancies Identified: 1647List only issues explicitly noted â omissions, duplications, dose differences, or contraindications. 1648 1649Recommendations: 1650Document only agreed changes â as stated. 1651 1652High-Risk Medication Review: 1653Note high-risk medications flagged â anticoagulants, insulin, opioids â only if discussed. 1654 1655Communication: 1656Record communication to prescriber and outcome â only if documented.`},{label:"Vascular Outpatient Consultation",category:"vascular",description:"Vascular history, risk profile, examination, imaging review & management plan",prompt:`Create a vascular surgery outpatient consultation letter with the following structure: 1657 1658Date, Clinician & Recipient: 1659Record date, specialist's name and role, and the referring clinician â as stated. 1660 1661Reason for Referral: 1662State the vascular indication â as documented. 1663 1664History: 1665Document vascular symptom history â claudication, rest pain, wound, aneurysm surveillance â only as explicitly stated. 1666 1667Cardiovascular Risk Profile: 1668Record only risk factors mentioned. 1669 1670Past Vascular & Surgical History: 1671List prior interventions â only as stated. 1672 1673Medications & Allergies: 1674Document as stated. 1675 1676Examination: 1677Record cardiovascular and peripheral vascular examination â only as explicitly described. 1678 1679Investigations Reviewed: 1680Summarise imaging and vascular laboratory results â only as discussed. 1681 1682Clinical Impression: 1683Record the vascular diagnosis or classification â only as explicitly stated. 1684 1685Management Plan: 1686Document the agreed pathway â only as stated. 1687 1688Follow-Up: 1689Record review or imaging interval â as discussed.`},{label:"Vascular Review Note",category:"vascular",description:"Interval history, objective findings, disease status & management update",prompt:`Create a vascular outpatient review note with the following structure: 1690 1691Date & Clinician: 1692Record as stated. 1693 1694Reason for Review: 1695State the purpose â post-procedure, surveillance, or symptom change â as documented. 1696 1697Interval History: 1698Document changes in symptoms or wound status â only as stated. 1699 1700Objective Findings: 1701Record examination findings and ABI or Doppler measurements â only as explicitly described. 1702 1703Investigation Results: 1704Summarise results since last visit â only as discussed. 1705 1706Disease Status: 1707Record change â stable, improved, or deteriorated â only as explicitly stated. 1708 1709Management Update: 1710Document any plan change â only as stated. 1711 1712Follow-Up: 1713State next review or surveillance interval â as discussed.`},{label:"Wound / Ulcer Assessment â Vascular",category:"vascular",description:"Wound type, bed, exudate, vascular assessment & dressing management plan",prompt:`Create a vascular wound or ulcer assessment note with the following structure: 1714 1715Wound Details: 1716Document location, dimensions, and wound type â arterial, venous, diabetic, or mixed â only as explicitly described. 1717 1718Wound Bed: 1719Record tissue type â granulating, sloughy, necrotic â only as described. 1720 1721Wound Edges & Surrounding Skin: 1722Document only as explicitly stated. 1723 1724Exudate: 1725Record amount and character â only as described. 1726 1727Infection Signs: 1728Document clinical signs â only if explicitly described. 1729 1730Pain Assessment: 1731Record pain score and character â only as stated. 1732 1733Vascular Assessment: 1734Record ABI, toe pressures, or Doppler findings â only if performed and stated. 1735 1736Current Dressing & Treatment: 1737Document wound management in place â only as described. 1738 1739Management Plan: 1740Record agreed changes â only as stated. 1741 1742Review Date: 1743State planned review â as documented.`},{label:"Vascular Imaging Request Note",category:"vascular",description:"Imaging modality, clinical indication, ABI results & management decision",prompt:`Create a vascular imaging request or ABI record with the following structure: 1744 1745Requesting Clinician & Date: 1746Record as stated. 1747 1748Imaging Modality Requested: 1749State the specific investigation â duplex ultrasound, CT angiography, MRA, or ABI â and vascular territory â only as explicitly stated. 1750 1751Clinical Indication: 1752Document the clinical reason and specific question â only as stated. 1753 1754Relevant Vascular History: 1755Include prior interventions and current symptoms â only as mentioned. 1756 1757ABI Results (if recorded): 1758Document resting and post-exercise values per limb â only if performed and recorded. 1759 1760Clinician Interpretation: 1761Record interpretation â only as explicitly stated. 1762 1763Management Decision: 1764Record management change â only as stated.`},{label:"Pre-operative Vascular Assessment",category:"vascular",description:"Pre-op history, investigations, anaesthetic 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1773Record medications and pre-operative changes â only as discussed. 1774 1775Allergies: 1776Record as stated. 1777 1778Examination: 1779Document cardiovascular and vascular findings â only as described. 1780 1781Investigations: 1782Summarise pre-operative results â only as reviewed. 1783 1784Anaesthetic Risk Discussion: 1785Record only as explicitly stated. 1786 1787Consent: 1788Note whether consent was discussed â only as documented. 1789 1790Pre-operative Plan: 1791Record instructions and scheduled operation date â only as stated.`},{label:"Post-procedure Vascular Review",category:"vascular",description:"Post-op status, wound & perfusion findings, complications & surveillance plan",prompt:`Create a post-procedure or post-operative vascular review note with the following structure: 1792 1793Procedure Performed & Date: 1794State the procedure and date â as documented. 1795 1796Post-procedure Status: 1797Document reported symptoms and recovery â only as stated. 1798 1799Examination: 1800Record wound site, limb perfusion, pulse status â only as explicitly described. 1801 1802Investigations: 1803Summarise post-procedure results â only as reviewed. 1804 1805Complications: 1806Record only complications explicitly documented. 1807 1808Management: 1809Document changes to wound care, medications, or further intervention â only as stated. 1810 1811Ongoing Surveillance Plan: 1812Record the imaging and clinic schedule â only as documented. 1813 1814Follow-Up: 1815State next review date â as discussed.`},{label:"Urgent Vascular Referral Letter",category:"correspondence",description:"Urgency, vascular indication, clinical summary & cardiovascular risk history",prompt:`Create an urgent vascular surgical referral letter with the following structure: 1816 1817Date & Recipient: 1818Record date and receiving vascular surgeon or service â as stated. 1819 1820Patient Details: 1821Document name, date of birth, contact, and identifier â as provided. 1822 1823Urgency: 1824State urgency â emergency, semi-urgent, or routine â only as explicitly stated. 1825 1826Reason for Referral: 1827State the indication â critical limb ischaemia, acute limb ischaemia, AAA, or other â only as documented. 1828 1829Clinical Summary: 1830Summarise examination, ABI, imaging, and current vascular status â only as stated. 1831 1832Relevant History: 1833Include cardiovascular risk factors, prior interventions, and medications â only as mentioned. 1834 1835Current Management: 1836Record treatment in place â only as stated. 1837 1838Specific Surgical Question: 1839State what is being asked â only as documented. 1840 1841Clinician Contact: 1842Include name, role, and phone â as documented.`}];e.s(["default",0,({visible:e,onClose:S,onConfirm:A,selectedTemplate:P,setSelectedTemplate:k,isLoading:N=!1,setActiveTab:j})=>{let{language:I}=(0,d.useLanguageStore)(),{fetchUsageInfo:M}=(0,R.useUser)(),[E,F]=(0,i.useState)(D),[B,T]=(0,i.useState)(null),[L,H]=(0,i.useState)(!1),[O,U]=(0,i.useState)(!1),[q,G]=(0,i.useState)(0),[V,_]=(0,i.useState)("form"),[W,z]=l.notification.useNotification({stack:!1}),{customCategory:K,loading:$}=(0,w.useCustomCategoryStore)(),Q=N||L||O,[J,Y]=(0,i.useState)("example"),[X,Z]=(0,i.useState)(""),[ee,et]=(0,i.useState)(!1),[ei,en]=(0,i.useState)(""),[ea,es]=(0,i.useState)(!1),[eo,er]=(0,i.useState)(!1),[el,ed]=(0,i.useState)(!1),[ec,em]=(0,i.useState)(!1),eu=(0,i.useCallback)((e,t)=>{},[]),ep=(0,i.useCallback)(async(e,t)=>{try{et(!0);let i=await (0,u.posterAIJSONOnly)(u.endPointsAI.previewTemplateExample,{structureText:e,templateName:t||""});Z(i.exampleReport||"")}catch(e){eu(e,"fetchExample")}finally{et(!1)}},[eu]),eg=(0,i.useCallback)(async(e,t,i,n)=>{try{H(!0);let a=await (0,m.poster)(m.endPoints.createTemplate,{templateName:e,userPrompt:t,visibility:i,template_category:n}),s=a?.data;T(s),Y("example"),ep(s.structureText,s.templateName),await (0,p.fetchAllTemplatesAndUpdateGlobalStore)(),M(!0)}catch(e){e.response&&alert(e.response?.data?.message||"An error occurred while creating the template. Please try again."),eu(e,"handleCreateNewTemplate")}finally{H(!1)}},[eu,ep]),ey=(0,i.useCallback)(()=>{T(null),F(D),Y("example"),Z(""),en(""),er(!1),S()},[S]),eh=(0,i.useCallback)(async()=>{if(!B)return;let e={id:B.id,structureText:B.structureText};try{U(!0),await (0,m.posterPut)(m.endPoints.updateStructureText,e),await (0,p.fetchAllTemplatesAndUpdateGlobalStore)(),j&&j("private"),er(!1),ed(!0)}catch(e){eu(e,"handleStructureEditSubmit")}finally{U(!1)}},[B,eu]),ef=(0,i.useCallback)(async()=>
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